What is an Autism Spectrum Disorder (ASD)?
Autistic Disorder
    Asperger’s Disorder
    Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS)
  What Do Autism Spectrum Disorders Look Like in Children and Adolescents?
    At Home
    At School
    At the Doctor's Office
  How are Autism Spectrum Disorders Treated?
    Behavioral Therapy and Psychological Interventions (Counseling)
    Biological Interventions (Medicines)
    Interventions at Home
    Interventions at School
  Helpful Resources
  Sources

What is an Autism Spectrum Disorder (ASD)?

An autism spectrum disorder (ASD), also called a pervasive developmental disorder (PDD), is a biological brain disorder that significantly affects an individual’s ability to understand people, interpret events, communicate, and interact with others. These disorders are described as occurring on a spectrum because of the wide variability of impact they may have on everyday functioning. The scope, variety, and severity of symptoms differ in each individual, but in general, autism spectrum disorders are characterized by:

  • Difficulty with communication
  • Impairments in social skills and understanding of how to engage and interact with others
  • Unusual behaviors and interests (such as attachments to unusual objects or speaking in cartoon or movie scripts)

Symptoms of autism spectrum disorders are usually identified by age 3, and researchers are now identifying ways to detect early signs in the first year of a child’s life. Early detection and intervention can significantly lessen a child’s symptoms.

The tendency to develop autism spectrum disorders involves complex genetic and biological factors that are still being determined. ASD occurs in boys four times more often than in girls. In the past, about 75 percent of children with autism were presumed to have mental retardation because of their low performance on standard IQ tests. It is now understood that because of the communication and perception deficits associated with ASD, these tests may not be able to provide an accurate measure of intelligence in an individual with ASD. As children with ASD become more verbal, they sometimes perform better on these tests.

It is widely believed that there has been a marked rise in the occurrence of ASD worldwide. Estimates of the incidence of autism spectrum disorders have increased over past decades from 1 in 2,000 children to current estimates of 1 in 250. This steep increase in the prevalence of ASD is due not only to the higher incidence but also to a growing understanding of the disorder, such that:

  • Criteria have become broader and include a wider spectrum of children
  • Diagnosis of mental retardation has diminished at the same time that diagnosis of ASD has increased, reflecting more sophisticated methods of distinguishing these conditions from each other

Certain rare medical conditions can be associated with autism spectrum disorders. Families should talk with their child’s clinician about medical conditions such as Fragile X (a chromosomal abnormality), or tuberous sclerosis (a condition that causes benign tumors), particularly if other family members have had unusual medical conditions or symptoms of ASD.

Five subcategories of ASD have been identified: autistic disorder (commonly called autism), Asperger’s disorder, pervasive developmental disorder - not otherwise specified (PDD-NOS), Rett’s disorder, and childhood disintegrative disorder. The most prevalent conditions -- autistic disorder, Asperger’s disorder, and PDD-NOS -- are discussed here. Rett’s disorder and childhood disintegrative disorder occur very rarely, but families should ask their clinician about them if a diagnosis of ASD is being considered. top

  Autistic Disorder

Autistic disorder is the condition commonly known as autism. A diagnosis of autistic disorder is made when, by age three, an individual displays six or more of 12 symptoms of impairment across all three major areas affected by ASD: communication, social interaction, and interests and behavior. Individuals with autistic disorder often appear aloof and uninterested in interacting with others, and they experience delays in speech development. Individuals with autistic disorder have severely impaired abilities to communicate, participate in social interchanges, and attend to things identified or pointed out by others. top

  Asperger’s Disorder

Asperger’s disorder is a condition with social and behavioral problems similar to autistic disorder, but with minimal or no apparent speech delay during the first 3 years of life. Communication skills are less affected than in children with autistic disorder. Some children with Asperger’s disorder have narrow and intense interests (such as fascination with weather conditions, train schedules, or historical dates) that lead them to develop knowledge of a particular subject that can be quite extensive compared to their age-similar peers. In addition, these children may be less interested in the breadth of activities typical of their peers, which further contributes to their social challenges. Asperger’s disorder is less impairing than autistic disorder and it may go undetected until middle school years, when the preoccupations and social difficulties become more impairing.

Some people with Asperger’s disorder have a neuropsychological profile known as Nonverbal Learning Disability (NVLD). NVLD has also been called “Right Hemispheric Insufficiency” since the affected skills are thought to be predominantly associated with the right side of the brain. Individuals with NVLD often have difficulties with a variety information-processing skills, including:

  • organization
  • adapting to change
  • math calculations
  • visual-spatial perception (affecting balance, sense of direction, and the ability to understand information presented in pictures and graphs rather than in words)
  • motor skills (affecting activities such as sports and handwriting),
  • inferential reasoning (arriving at information that is implied but not directly stated)
  • the subtleties of social relationships (for example, understanding when to let others speak, accurately “reading” nonverbal cues such as facial expressions and tone of voice to assess others’ feelings)

People with NVLD are usually quite articulate speakers but often have trouble putting their thoughts in writing.

Students with these discrepancies in their abilities may experience frustration in both academic and social situations, especially as the complexities in both domains increase sharply in the middle school years. As a result of their perceptual and related difficulties, people with NVLD sometimes have difficulty in sports, may feel socially isolated, and may be accused of stubbornness and laziness when seemingly manageable work overwhelms them. NVLD sometimes leads to depression and anxiety disorders.  top

  Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS)

The diagnosis of PDD-NOS is given to children who meet some, but not all, criteria for a specific autism spectrum disorder, such as autistic disorder or Asperger’s disorder. Since this diagnosis hinges on a child not meeting “full” criteria for an ASD, it usually reflects a less severe disorder. Clinicians use this diagnostic category when there is a significant impairment in the development of reciprocal social interaction or communication skills, or when stereotyped behavior, interests, and activities are present. As with all of the autism spectrum disorders, the symptoms of PDD-NOS vary considerably from one person to another.

Clinicians and researchers continue to refine the criteria for these disorders. In the interim, families, clinicians and researchers must contend with variation in the way diagnostic terms are used for ASD. Talking with a clinician about symptoms and clarifying diagnostic terms is often helpful for families. top

What Do Autism Spectrum Disorders Look Like in Children and Adolescents?

Children with ASD are generally noted early in life to have developmental delays. Symptoms of ASD are increasingly identified within a child’s first 18 months of life. Language delay is the most common reason families seek evaluation. Some children may have delayed speech, while other children speak with unusual patterns. Examples of unusual speech include repeating phrases spoken to them (known as echolalia), using phrases in unusual ways (including scripted language where the child responds to different comments from family using the same verbal responses, such as “Want milk” when the child wants a snack or toy), ), saying the same phrases over and over again (known as perseveration), and reversing pronouns (saying “You want juice,” when the child wants juice). Children may not use language at all when interacting with others, or they may speak in a monotone that sounds “flat.”

The problems with social interactions stem from an impaired ability to perceive events and interpret communication accurately from others. Because of this impairment, children with ASD have unusual and unexpected responses to their surroundings, including a tendency to interact less with others. Young children may make less eye contact with others, may not make eye contact when spoken to, and may seem to avoid eye contact in general. They may express fewer emotions on their faces. They may appear to have less interest in sharing their discoveries with others and prefer to intently focus on an object rather than show it to a parent. There may be less pointing at objects for others to find, less following the pointing of others, and less reciprocal giving and taking of objects, in comparison to peers. Unlike their same-aged peers, children may also have difficulty appreciating that others have their own thoughts and wishes. Despite these challenges, children may have certain kinds of interests in others, so the presumption that they lack this interest may not always be accurate.

Because of their difficulties with social interaction and, in some cases, communication, children with autism spectrum disorders may be easily misunderstood. Simple requests from a parent may not produce the expected response, leaving both the parent and child frustrated or confused. Children may be perceived as stubborn. When rigid adherence to daily activities is often seen in children with ASD, this generally reflects their underlying need for routine and predictability rather than intentional manipulation of parents.

Children with autism spectrum disorders often have unusual interests or behaviors, and their play may appear less imaginative and more repetitive. They may be more interested in parts of an object rather than the whole object. For example, rather than playing with a toy car in the typical way, a child with ASD may spend extensive time focusing on lining up cars or just spinning their wheels over and over. Children may also be attached to odd items that are hard or technical rather than cuddly. For example, a child may be particularly attached to a plastic lid and insist on keeping it nearby at all times, rather than a soft stuffed animal or blanket. In other cases, a child may be attached to a category of items, such as magazines, but not have a preference for which magazine is in hand. Unusual behaviors include sitting with legs in a “W” position instead of with crossed legs, hand flapping, repeated spinning, walking on toes, or other movements that are repeated without clear purpose.

Often children with ASD have sensory integration difficulties, causing them to be either highly sensitive or underresponsive to sound, light, and other sources of stimulation through the senses. They may overreact to sounds, grabbing their ears when hearing an unexpected sound (such as a bell or siren), and yet talk very loudly when speaking to others. They may object to rough-textured clothing on their skin or tags inside their clothes. They may eat a very restricted range of foods or textures, and may tolerate hugging but become irritable when touched lightly. This sensory sensitivity, sometimes called “tactile defensiveness,” can make these children appear even more disinterested in others, as physical contact may irritate rather than console these children.

Cognitive abilities vary widely. Many children with ASD have some degree of mental retardation, while other children do not. Some children with autism disorder or Asperger’s disorder are particularly gifted in certain areas, such as music, math, or art. This “savant” category is actually quite small, and it is currently estimated that less than 1 percent of ASD children have these exceptional talents or “splinter abilities.” If these abilities are present, they are usually recognized by age 10. Autistic savants became more widely known with the release of the 1988 movie Rain Man, in which the character Raymond could instantly determine the day of the week for distant dates and was able to multiply extremely large numbers in his head.

Programs or interventions that are beneficial to children with autism spectrum disorders may not be effective for these children as they become adolescents. With the right ongoing interventions, however, young people with ASD usually can continue to make progress. For example, adolescents may increasingly seek social interactions though they still may not have the skills of their peers to initiate and maintain social relationships. In adulthood, people with autistic disorder, PDD-NOS, and Asperger’s disorder may continue to make gains, although sometimes more slowly. They often still have notable difficulties "putting it all together" to lead an independent life, and many require assisted-living supports to participate fully in community life.

Diagnosing autism spectrum disorders requires a trained clinician (such as a pediatrician, child psychiatrist, child psychologist or pediatric neurologist) who can integrate information from home, preschool/daycare, and the clinical visit to make a diagnosis. top

  At Home

Children with any of the autism spectrum disorders may show some of the following symptoms at home.

  • Significant impairment in nonverbal communications, such as eye contact, body gestures, and facial expressions
  • Apparent lack of interest in sharing pleasures with others. The child may not point to items of interest or show objects to others.
  • Diminished ability to reciprocate verbally, emotionally, or socially when someone tries to interact with the child
  • Inability to develop friendships appropriate for the child’s age. Frustration may develop as children grow, particularly in those children with Asperger’s disorder, when they have some recognition that they have trouble making friends. Children with more severe delays may not notice these difficulties.
  • Preoccupation with unusual interests. For example, a child may have a consuming interest in holding a magazine, though the child does not seem interested in the magazine contents.
  • Interest in parts of objects, such as the corner of a box or the wheels of a toy car
  • Repeated movements that are unusual, such as hand flapping or complex, whole-body movements
  • Rigid adherence to particular routines, even if the routines have no apparent purpose, such as lining up items in a particular order, or wearing certain clothes a certain way, regardless of the weather outside that day. Tantrums may occur when the child’s rigid habits are shifted (for example, when the child’s bedtime is changed).
  • Emotional reactions that are erratic or hard to understand. A child’s strong emotional response may seem to occur suddenly or may not make sense to others. Emotional responses are often dramatically out of proportion to events (for example, throwing food or dinnerware if the child sees carrots on the dinner plate). Because the child may not be able to articulate feelings well using language, he or she may instead demonstrate intense or unusual behavior as a way of communicating.
  • Depression or thoughts of not wanting to be alive may develop in some adolescents with ASD, particularly in those with Asperger’s disorder, when they want to have meaningful friendships but believe there are no interventions to help them break out of their social isolation.

In addition to the above symptoms, children with autistic disorder may have a combination of the symptoms listed below.

  • Delayed speech or lack of language development. Unlike children with communication difficulties due to other causes, such as deafness, children with autistic disorder generally do not attempt to compensate for these delays with gestures.
  • Difficulty starting or maintaining a conversation, in cases where children have the ability to speak
  • Repetitive or unusual language, such as “scripted language” heard in videos/movies/television/recordings, or reversal of pronouns (“You want cookie.”)
  • Limited imaginative play. The play of children with autistic disorder may demonstrate fewer variations, less spontaneity, and less imitation of others, and indeed may repeat the same play (set up toy cars, then kick them) over and over.
  • Cognitive delays and delays in self-care may be evident. Children with autistic disorder may have some degree of mental retardation. top
  At School

At school, a child’s symptoms of ASD may be expressed in any of the following ways, in addition to the symptoms listed above.

  • Difficulty following instructions. Delays in communication, cognitive, and social skills all may contribute to problems following simple instructions. A child may not respond to a direction or may begin a different task.
  • Concrete responses to tasks. When shown a picture of a house and told to “color in your family’s home,” the child may want to go home, believing that he needs to use crayons on the walls of his family’s house.
  • Unusual style of communication. A child may speak with reversed pronouns (“You want the book” when referring to self), stereotyped phrases (“Ready for school” when referring to readiness to go to a party), repeated phrases, or literalness (believing a parent will hunt for a new automobile when the parent says, “If there’s not enough room for all of us for this trip, we’ll just have to find another car”).
  • Limited range of expression. Children may not be able to continue a conversation and may instead give a one-word answer. Their speech may be delivered in a monotone voice.
  • Difficulty focusing on the person speaking. Children may make little or no eye contact with the person talking to them. The child may also be easily distracted by sounds, noise, peers, or even objects in the classroom.
  • Irritability, upset, tantrums, or distress for no apparent reason. Children may be distressed for reasons they cannot express or for reasons that may seem insignificant to others. For example, when items such as seasonal decorations or art projects are removed from the classroom, children may become distressed by their absence. Similarly, adding new items to a classroom, rearranging items in a room, or the detection of inconsistencies (such as noticing a rubber base to one chair leg is missing) can be upsetting.
  • Conflicts with peers. Conflicts may arise due to the child’s lack of understanding of others’ perspectives. For example, a child may grab a toy without appreciating that another child was playing with it, change a peer’s project without realizing that the peer will be upset, or repeat a wish insistently without appreciating that the class has a new task.
  • Additional mental health conditions or learning disorders. Children with ASD may have attention problems, difficulties controlling emotions, or other learning difficulties.
  • Medications may have behavioral or cognitive effects. Once a child is receiving treatment for symptoms, changes in mood or behavior should be discussed with parents, as these changes can reflect medication side effects. top
  ► At the Doctor's Office

Autism spectrum disorders may be evident during an office visit if a child makes little eye contact with the clinician, has little interest in the interaction, or becomes preoccupied with an unusual object in the room. However, the child’s range of symptoms may not be immediately evident at the doctor’s office. If ASD is suspected, clinicians will benefit from talking with parents, daycare/preschool or school staff, and other important caregivers to evaluate a child’s functioning in each area to clarify the underlying cause of the child’s symptoms.

Clinicians may encounter some of the following challenges in diagnosing and treating a child or adolescent with an autism spectrum disorder:

  • Symptoms vary over time and their appearance changes as a child grows. A clinician may need to see a child over time to determine the appropriate diagnosis. It is typical for a child’s social, communication, and behavioral symptoms to shift as the child gets older. A clinician will need to continue to evaluate the child and tailor interventions as the child matures.
  • Other conditions may look like ASD. Other conditions that have features similar to ASD include hearing impairment or deafness, childhood schizophrenia, mental retardation, and attachment disorders. All of these conditions have features which help distinguish them from ASD.
  • Mood, anxiety, or attentional disorders may also be present. Children may have a mood disorder (such as depression or bipolar disorder) or an anxiety disorder (such as a specific phobia). Children’s symptoms may have significant overlap with symptoms of obsessive-compulsive disorder (OCD). Anxiety is often a component of ASD. Children’s behaviors may also appear to be similar to behaviors in attention deficit/ hyperactivity disorder (ADHD), although typically children with ASD do not respond predictably to stimulants.
  • Certain medical conditions can cause symptoms similar to ASD or may be present in children with ASD. These conditions include neurological disorders (seizure disorders, tuberous sclerosis), genetic disorders (Fragile X), metabolic disorders, and sensory disorders (deafness). Relevant laboratory tests, physical examinations, and neuropsychological evaluations may be helpful when the child’s history raises concern about other underlying medical conditions.
  • Speech, language, motor, and sensory problems (hearing, vision) may need evaluation by specialists, such as speech therapists and occupational therapists. Children who do not speak or whose language does not develop in a typical way, who sit in the “W” position, walk on tiptoes, refuse to wear clothes, or cannot tie shoes, hold objects, twist lids, or perform other developmentally expected daily life activities often require specialized interventions by speech or occupational therapists.
  • Phrasing questions with sensitivity may allow a more complete picture of symptoms to emerge, though the child may not be able to answer the questions or provide insight regarding symptoms. Parents and teachers can provide key descriptions of symptoms in children. While some adolescents with Asperger’s disorder may be more able to describe their symptoms and frustrations, others may not be able to grasp or describe the nature of their delays.
  • Families may need support about what they can reasonably expect from their child. Children with ASD will benefit if their family understands that therapy and medicines may reduce, but do not cure, symptoms. Families should be informed that the degree to which the child will improve with treatment varies considerably among individuals. Families may attempt many types of interventions to alter the condition and may feel guilty if the interventions agitate the child or do not work.
  • Families may be overwhelmed when they learn their child has an autism spectrum disorder. While a diagnosis of ASD may explain some concerns parents have had about their child, it can be a life-changing and difficult piece of information for parents to accept. Parents may appreciate information about support groups and other resources.

The demands of daily life with an affected child can place significant stress on parents and siblings. Some parents may “sacrifice” themselves to manage the child with ASD, which can produce frustration for all and leave other family members feeling neglected yet guilty. Respite services or other options for parents and siblings to "take a break" should be discussed with families if they appear to be stressed by the demands of living with a child who has ASD. top

How are Autism Spectrum Disorders Treated?

In general, the earlier treatment is started, the greater the odds it will be effective. Interventions, especially very early in childhood, often reduce or improve some of the child’s symptoms, but are not curative. Treatment involves ongoing interventions provided by a team consisting of the child’s medical practitioners, plus therapists, school staff, and family. These treatments include behavioral therapy and psychological interventions (behavioral programs, counseling), biological interventions (medicines), and accommodations at home and school that reduce sources of stress for the child. Other types of therapy may also be appropriate, such as occupational therapy or speech therapy. Open, collaborative communication between a child’s family, school, and treatment professionals optimizes the care and quality of life for the child. top

  Behavioral Therapy and Psychological Interventions (Counseling)

Autism spectrum disorders are caused by complex genetic and environmental factors beyond the control of the child or the child’s family. Everyone interacting with the child should understand that ASD symptoms are not signs of stubborn behavior or flawed parenting. Educating family members about the features of ASD and effective interventions is key to successful treatment. Parents should discuss their child’s particular needs with their clinician to determine which treatments will be most beneficial for their child.

  • Speech, behavior, and occupational therapy provided early in a child’s life have been found to be particularly beneficial to a child’s cognitive, communication, and behavioral skills. These therapies, which may be needed on an ongoing basis, are available through Early Intervention programs offered by state agencies and school districts. While these interventions do not “cure” ASD, they can reduce a child’s symptoms and improve their course.
  • Parent training in behavior therapy can provide parents with key tools to encourage desired behaviors and reduce undesired behaviors. This training teaches parents that small rewards, or positive reinforcement, promotes preferred behaviors. Parents learn that attention to negative behaviors may unintentionally reinforce problem behaviors. When undesirable behaviors occur, the parent needs to teach the child an alternative, acceptable behavior to replace the undesirable one. It is not enough to “just say no,” since the child doesn’t know what to do instead.
  • Parent guidance sessions can help parents manage their child’s symptoms, identify parenting skills to employ when the child’s symptoms are more severe, learn how to function as a family despite the child’s symptoms, and address complex feelings that can arise when raising a child with a chronic and pervasive disorder. Family therapy may be beneficial when difficult issues are affecting the family as a whole.
  • Group psychotherapy allows a child to practice language, behavior, and social skills in a carefully structured setting. Social skills training groups teach children to assess their behaviors in social settings and provide guidance in appropriate social behaviors. These groups rely on modeling and contingency management (small rewards for good behaviors) to encourage effective social skills. Group therapies can also be valuable to a child by providing a safe place to talk with other children who face adversity. At the same time, groups comprised only of children with ASD are often less effective for teaching social skills than those that include some age-similar peers without ASD.
  • School-based counseling assists a child in adjusting to the demands of school. School counselors can develop helpful techniques to aid a child in the classroom, on the playground, and during the transition between school and home. School counselors can also work closely with school consultants, a child’s treatment team, and a child’s parents to develop school-based interventions. Sometimes school counselors support the school staff working daily with the student to aid staff in continuing to improve approaches for these complex children.
  • Individual psychotherapy may be helpful, particularly for adolescents with Asperger’s disorder, to address particular social, emotional, or behavioral issues. Cognitive behavior therapy with an adolescent or young adult with ASD may be useful in addressing similar issues. top
  Biological Interventions (Medicines)

No medication currently "treats” ASD or is FDA-approved specifically for the treatment of any ASD, although many medications approved by the FDA for other uses and age groups have been tested and may improve certain ASD symptoms in children. Physicians prescribe these medications to treat particular ASD symptoms. For two reasons, these medications are often used in much lower doses when treating ASD than when treating other conditions. First, children with ASD sometimes experience the benefits of medications at much lower (one tenth of normal) doses, and second, children with ASD are sometimes more susceptible to adverse side effects when given higher doses.

The following medications may be prescribed to treat symptoms of ASD:

  • Antipsychotic medications (including Abilify, Geodon, Haldol, Risperdal, Seroquel, Zyprexa, and others). These medicines, also known as neuroleptics, were originally designed to treat problems with disorganized thinking but may reduce rigidity, repeated movements, intense activity, and aggressive behavior. These medications may also facilitate adaptability, learning, and the ability to relate to others.
  • Antidepressants. These medicines were originally designed to treat depression but may reduce repetitive or compulsive behaviors in children with ASD. The most commonly prescribed agents, including Celexa, Lexapro, Luvox, Paxil, Prozac, and Zoloft, belong to a group of medications called Selective Serotonin Reuptake Inhibitors, or SSRI’s. Anafranil, an antidepressant medication that also has anti-compulsive properties, is often effective in treating these symptoms as well.
  • Other medications. The following medications are occasionally considered as supplements to the above medications, though there is less information about their effectiveness.

    • Clonidine (Catapres) and guanfacine (Tenex), medicines originally developed to treat hypertension in adults, may increase behavioral control and diminish impulsive or hyperactive behaviors in children with ASD
    • Stimulants (Adderall, Concerta, Dexedrine, Focalin, Metadate, and Ritalin) may improve attention and sometimes decrease impulsive and hyperactive behaviors. However, stimulants may aggravate behavioral symptoms, so benefits compared to risks/side effects must be examined in each individual case to determine if a stimulant should be continued.
    • Buspirone (Buspar), developed to treat anxiety, and propanolol (Inderal) and atenolol (Tenormin), developed to treat hypertension, have been employed to treat aggression in children with ASD, though results are variable and children may become tolerant to these medications, leading to decreased effectiveness.
    • Mood stabilizer medications, such as valproate (Depakote), lithium, gabapentin (Neurontin), and carbamazepine (Trileptal/Tegretol), are also used in children with ASD to decrease volatility and sensory sensitivity.

Again, no specific medication has received FDA approval for use in ASD, although many of these agents have been studied in children and adults with ASD.

These medicines generally begin to be effective in reducing symptoms within 2-4 weeks of starting treatment, although stimulants and antihypertensive medications begin to be effective after they are taken for 1-2 weeks. Fully 12 weeks may be required in order to determine whether medication is going to be effective for a particular individual. Dose adjustment is frequently needed to determine the most helpful medication dose. Medications should only be started, stopped, or adjusted under the direct supervision of a trained clinician.

There is no "best" medicine to treat autism spectrum disorders, and it is important to remember that medicines usually reduce rather than eliminate symptoms. Different medicines or dosages may be needed at different times in a child's life or to address the emergence of particular symptoms. Successful treatment requires taking medicine daily as prescribed, allowing time for the medicine to work, and monitoring for both effectiveness and side effects. The family, clinician and school should maintain frequent communication to ensure that medications are working as intended and to monitor and manage side effects.

The following cautions should be observed when any child or adolescent is treated with antidepressants.

  • Benefits and risks should be evaluated. Questions have arisen about whether antidepressants can cause some children or adolescents to have suicidal thoughts. The evidence to date shows that antidepressants, when carefully monitored, have safely helped many children and adolescents. The latest reports on this issue from the U.S. Food and Drug Administration can be found on its web site at www.fda.gov. Consideration of any medicine deserves a discussion with the prescribing clinician about its risks and benefits.
  • Careful monitoring is recommended for any child receiving medication. For children with ASD, medications should usually be started at very low doses, and slowly increased (for example, starting Prozac at 1-2 mg and going up by 1 mg every 1-2 weeks). Though most side effects occur soon after starting a medicine, adverse reactions can occur months after medicines are introduced. Agitation, restlessness, increased irritability, or comments about self-harm should be addressed immediately with the clinician if any of these symptoms emerge after the child starts an antidepressant.
  • Some children with autism spectrum disorders may also have bipolar disorder. In some individuals with bipolar disorder, antidepressants may initially improve depressive symptoms but can sometimes worsen manic symptoms. While antidepressants do not “cause” bipolar disorder, they can unmask or worsen manic symptoms.

Helpful information about specific medications can be found at www.medlineplus.gov (click on “Drug Information”) and in the book Straight Talk About Psychiatric Medications for Kids (Revised Edition) by Timothy E. Wilens, MD.   top

 ► Interventions at Home

At home, there are a number of ways that parents can actively support their child’s needs.

  • Understand the disorder. Understanding the nature of ASD and how the child experiences it will help parents sympathize with a child’s struggles.
  • Make peace with being “different.” Parents have an important and sometimes challenging task in accepting that their child will be different from other children. Parents may be more distressed than their child when the child does not follow a “typical” age-appropriate course. Meeting the child at the child’s level will best promote growth. Goals focused on helping the child enjoy as much of daily life as possible may help parents feel less stressed about intervening and “fixing” this disability.
  • Establish consistent routines. Children with ASD are more likely to do well in settings with predictable schedules. Setting a time and regular routine for homework, dinner, sleep, and play helps the child understand and meet expectations. These times should be clearly explained to the child and even written down or provided with pictures in a familiar place.
  • Identify special places for homework. A child may need a “special spot” or quiet place where distractions are reduced, such as a place away from the front door. Parents may need to remove distracting items for the area to be effective. Turning off televisions, computers, and telephones can reduce distractions.
  • Prepare the child for deviations from familiar routines by telling him or her in advance what is planned. While parents might think the child would welcome a trip to an ice cream parlor, or a trip to Disney World, if unable to navigate the changes required to go to these places, the child may “melt down” or resist these well-intended offerings. In providing the information, parents must balance their children’s reduced ability to process long verbal explanations against the children’s need for concrete and perhaps detailed descriptions that can help them prepare for the change. Accordingly, parents (and school staff) may have to describe explicitly the details of the event: “Mommy will pick you up at school early, at 2:30, so we can go and have ice cream. Mommy will bring your four toy cars so you can play with them while we drive.”
  • Support the child’s interests. Though the child’s interests may be different from peers (for example, wanting an unusual food or activity at his or her birthday party), it is helpful to support the child’s wishes whenever possible and reasonable. Fostering the child’s creativity is beneficial to the child.
  • Encourage activities to develop the child’s communication and social skills, as described below in Interventions at School
  • Enlist the help of other family members. Siblings deserve ongoing praise and recognition for providing helpful assistance to the child.
  • Bring interventions into the home. Therapies can be particularly effective when they are started at an early age and carried out throughout the week. Some families bring therapists into the home to work on communication skills and social interaction. Parents can also be trained in therapy techniques.
  • Listen to the child’s feelings. The simple experience of being listened to empathically may have a helpful effect. Listening to a child’s feelings may also help parents develop successful strategies with their child.
  • Praise the child’s efforts. Young people often feel like they only hear about their mistakes. Even if improvements are small, every good effort deserves to be praised.
  • Behavioral plans may be useful to reinforce a child's successful efforts. Children tend to benefit from behavioral plans that reward good behaviors (rather than punish misbehaviors) because they may otherwise feel as though they get feedback only about their mistakes. Suggestions for effective behavioral plans are shown below.
Succeeding with Behavioral Plans
  • Provide the child with frequent acknowledgements of success. Experts encourage doing this six times per hour at home. This pattern may not be one parents grew up with, but it is an easy and effective means to help a child develop new habits. For example, telling a child, “Great job getting the table cleaned off with no sticky spots at all,” is preferable to, “I’ve told you twice already to go pick up your clothes once you get the table cleaned off.” For children with ASD, however, “less is more” is generally the rule with verbal statements, so brief comments “Great job cleaning the table,” or even nonverbal acknowledgements (smiling and thumbs-up gestures) may be more effective.
  • Reward the child for making efforts to reduce problem behaviors. Avoiding a meltdown, demonstrating flexibility in a potentially difficult situation, or increasing times without an angry episode can improve daily life, and all of these successes warrant acknowledgment or reward.
  • Develop meaningful incentives with the child. Praise, gold stars on a calendar, or sitting beside a parent or friend in the car can all be effective rewards. Parents will need to determine with their child what the reward is, and parents will also need to be consistent with the plan for it to be effective. Tangible reminders help children learn that they can be responsible for their actions and will be recognized for their good efforts. Parents can look to the school psychologist, guidance counselor, or their child’s treatment professionals for help in developing behavioral plans for the home.
  • A chart system is often effective, in which a certain number of stars per day may be “cashed in” for the reward (an extra story with parent, a trip for ice cream, etc). It is essential that these rewards not become the source of additional conflict. For children with ASD, often these rewards must occur within the day, if not hours, of successful efforts, so weekly or monthly charts are often unhelpful for young children with ASD. “Taking away” stars or rewards usually escalates conflicts, so providing a reward once the child obtains 5 stars often works better. top


  Interventions at School

School-based interventions are vital to aiding a child with ASD. There are many ways that schools can help a child with ASD succeed in the classroom. These methods are particularly helpful when they are provided to a child throughout the school day in a year-round program. Integrating methods at home and school allows the child to develop and maintain new skills. Meetings between parents and school staff, such as teachers, guidance counselors, specialty therapists (such as speech/language and occupational therapists) and nurses will facilitate collaboration to develop helpful school structure for the child. The child may need particular changes (accommodations/modifications) within a classroom. Examples of some accommodations, modifications, and school strategies include the following options.

For communication interventions:

  • Promote language development by creating opportunities to use communication skills
  • Assist the child’s communication by providing pictures the child can point to when necessary. These visual aids will promote the child’s success at conveying thoughts and foster a positive experience for everyone in the classroom.
  • Support the message with visual cues. By pairing words with appropriate, simple gestures, a child may more readily understand the message.
  • Clearly indicate when instructions are given (for example, “Peter, this is a direction”). A child with ASD often misses basic social cues.
  • Keep it short and sweet. The child will understand short sentences more easily than long sentences. One or two word statements work well. For example, say, “close” and “book,” rather than, “Now, it’s time for you to close your book.”

For social interventions:

  • Teach the ABC’s of a conversation. Instruct the child how to begin a conversation, reply to others’ responses, and end a conversation.
  • Practice social skills. Children with ASD need to learn social skills the way other children learn reading or writing skills. Step-by-step exercises that are clearly described, written, reviewed and rehearsed are helpful. These may include a broad range of routine social activities (such as arriving at school and settling into a chair, raising a hand to answer a question, or sharing a toy at recess). Start with an easy social activity, and tell the child that practicing that skill will be his or her special project for the week. Review the steps (“First look at me. Then say my name. When I look at you and say your name, then you can ask your question”). Providing positive feedback is helpful.
  • Role-play social interactions using a script with simple steps. Read and review “social stories” with the child. These are illustrated vignettes designed for children with ASD, which offer reassuring lessons written in simple language on how to act and what to expect in specific circumstances. Social stories provide guidance for common social situations and explain the meaning of many everyday interactions.
  • Identify opportunities for the child to work with another student
  • Support the child’s efforts by designating a helper. Another student or adult can help the child when interacting with others.
  • Teach the child to become aware of others’ thoughts or feelings, clarify intended statements when the child makes literal interpretations, and help the child to understand humor and jokes.

For behavioral interventions addressing repetitive actions, unusual behaviors, or limited interests:

  • Prioritize behaviors to be addressed. Priority may initially be given to safety issues.
  • Identify appropriate times/places when the child can move. Children with ASD may need to move about more frequently than other children. They may need significant support to wait for such times, or they may need to be allowed a less disruptive form of movement.
  • Before an activity, clarify expectations. Identifying the expected volume level and activity level before unstructured activities will help reinforce desired behaviors.
  • Offer alternative activities, particularly when the child is experiencing sensory overload
  • Suggest a comparable substitute for activities causing concern. For example, ask the child to play a video game involving driving cars instead of an aggressive, first-person shooter video game. An alternative that is one step different from the child’s preferred play may be accepted by the child more easily than an activity that is unrelated.
  • Assign the child a seat that limits distractions. Sitting at the front of the class may be helpful.
  • Provide an alternative, less distracting source of activity, such as a squeezeball or fabric to rub
  • Additional aids may help reduce distractions or disruptions. Children with ASD may be particularly sensitive to sounds or to particular types of touch. Noisy classroom chairs can be quieted with tennis balls or padding at the end of the legs. Firm touch or hugs may be tolerable while light touch may irritate the child.

For all children with ASD:

  • Encourage the child to help develop interventions with adults. Enlisting the child in the task will lead to more successful strategies and will foster the child’s ability to problem-solve.
  • Develop a behavior plan that is a true incentive to the student, as described above in Interventions at Home. Rewards may be given at school by a teacher or school counselor or at home by a parent. Teachers, school counselors, and parents can collaborate to use similar reward systems at school and home.
  • Reward a child’s efforts. Every good effort deserves to be praised.
  • Please click on School-Based Interventions for a more complete list of school accommodations for children with autism spectrum disorders.
Approaches to Teaching Behavior and Social Skills
at School, Home, and Beyond

Generally, techniques for teaching social interaction and behavior need to be employed at least several hours each school day to be effective for a child. Programs often schedule 20 hours of weekly behavioral interventions during school hours, though individual schedules can range from 18 to 40 hours per week. As children gain skills, they increasingly are able to learn in programs relying on verbal and social skills.

The success of any program requires tailoring interventions to meet the child’s specific needs. Consequently, programs may vary for children in the same classroom, depending on the children’s developmental levels, symptoms, medical conditions, response to the program, parental ability to continue interventions at home, and other factors. Programs also need to review a child’s treatment plan regularly to allow adjustments in content and hours, according to the child’s response.

Behavioral interventions are designed to increase desired skills while decreasing problem behaviors. Behavioral interventions, coupled with educational programs, have become a primary way to teach and treat children with ASD. Successful programs often incorporate the following features: 1) methodical use of behavioral interventions, 2) focused work between the child and therapist/teacher, often one-on-one, and 3) parent education that allows parents to continue interventions at home. Children with greater needs may benefit most from behaviorally oriented programs.

Schools increasingly use programs that systematically evaluate a child’s behavior and identify interventions tailored to each child. This systematic approach to developing a program for each child is often called applied behavioral analysis (ABA). Applied behavioral analysis provides a general structure to work with a child. The first step of ABA is an initial assessment of the child, in which the child’s skill needs and strengths are identified. The next step is determining appropriate educational and treatment goals for the child, based on the initial assessment. Each big-picture goal is broken down into the many individual skills needed to achieve the goal. These individual skills are then arranged in a step-wise manner, to facilitate successful skill building for the child. In the end, a program or curriculum is developed that addresses many areas of the child’s functioning (such as skills in academics, communication, imaginative play, social activities, and motor abilities).

Programs that use ABA principles employ a variety of techniques to help children develop new skills. One technique frequently used is called discrete trial training (DTT). In a discrete trial, the teacher or clinician gives the child an instruction (for example, “point to the green circle”). The adult may give the child a prompt to help the child with the task (the adult points to the green circle). If the child does not give the correct response, the adult may give the child another chance, again with prompts to assist the child. When the child provides the correct answer, the child is given a small reward, also known as a positive reinforcement, along with praise (as an example, the adult gives her a star sticker and says “Great job”). The idea behind DTT is that a child will learn desired skills, discover that learning is fun, and increasingly respond to verbal instructions and praise.

Additional behavior analysis techniques are emerging, particularly those that work with behaviors already enacted by the child, so that “chains” of more complex behaviors can be “assembled” (putting on and tying shoes, cleaning up after eating, doing a real-world math problem). Many of these techniques are described on web sites listed under Links & Books.

Floor time is another technique employed by some families at home or adapted for schools. Floor time involves playing with a child in 20-30 minute sessions, multiple times throughout the day. This technique teaches parents (or teachers) how to “attune” to the child’s needs and skills while shaping the child’s behavior, according to the child’s current developmental level. Caregivers follow the child’s lead in choosing the type of play activity, and very gradually introduce incremental complexities to the interactions of play. Over time the child learns about novel ways of play that expand his or her understanding of relationships and include the perspective of others. Again, this is one of many techniques that may be employed at home or school.

Flexibility and a supportive environment are essential for a student with an autism spectrum disorder to achieve success in school. School faculty and parents together may be able to identify patterns of difficulty and develop remedies to reduce a child’s challenges at these times. top

Helpful Resources

Many online resources and books are available to help parents, clinicians, and educators learn more about children and adolescents with autism spectrum disorders. Click here for a wide selection of resources. top

Sources

Information provided above on ASD draws from sources including:

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington DC, American Psychiatric Association, 1994

Bostic, JQ, Bagnell, A. School Consultation. In Kaplan BJ, Sadock VA. Comprehensive Textbook of Psychiatry, 8th edition. Philadelphia: Lippincott Williams and Wilkins, 2004

Clinical Practice Guideline: Report of the Recommendations. Autism/Pervasive Developmental Disorders, Assessment and Intervention for Young Children (Age 0-3 Years). 1999 Publication No. 4215 – from the NYS Department of Health, Early Intervention Program

Dulcan, MK, Martini DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington DC, American Psychiatric Association, 1999

Lewis, Melvin (ed.) Child and Adolescent Psychiatry: A comprehensive Textbook, 3rd Edition. Philadelphia, Lippincott Williams and Wilkins 2002   top

 



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2010 Massachusetts General Hospital, School Psychiatry Program and Mood & Anxiety Disorders Institute Resource Center